Thursday, March 27, 2008

NewFNP's clinic so rarely prescribes scheduled drugs that newFNP always feels a little hesitant to write for them. Of course, there are exceptions to this, but these exceptions tend to occur in established patients with acute pain or anxiety or what-have-you.

They do not tend to occur with new walk-in patients who are at their third clinic in six months, who slur their speech and who disclose that they have been on SSI and have never worked due to asthma and back pain and knee pain and arthritis. And who need Trazadone and Lorazepam to sleep every night.

Now, newFNP is sympathetic to the fact that people have and need treatment for pain and anxiety. NewFNP is aware that people who are dependent on narcotics often need more narcotics to control their pain. But newFNP's clinic is a) not a pain management clinic and b) situated in a crappy neighborhood with enough of a drug problem.

And this patient was, frankly, just full of red flags.

So newFNP decided that she would refill this patient's lorazepam - it's not oxycontin after all - but that she would only give her 10 tablets while she awaited the medical records from her former provider. Ditto the Trazadone.

Fucking hell, did the encounter ever go to the dogs! NewFNP, apparently, had offended this patient by telling her that she needed to see her voluminous medical record before being able to continue her medical excuse for SSI and that 10 lorazepam was unacceptably stingy. She was quite clear in her dissatisfaction. Her exact words to newFNP were, "I need 10 lorazepams just to deal with people like you!" It was a refreshingly honest statement. She then informed newFNP that she will be no longer seeking care at newFNP's urban community health clinic, or more specifically and pointedly, with newFNP.

NewFNP breathed sigh of relief.

NewFNP probably could have handled this encounter better, but so could have newFNP's patient. Like, for instance, slurring during the encounter generally does not bode well when one is seeking anxiolytics ad libitum.

In retrospect, newFNP is sure that she had judgment in her voice when she told her patient about not freely authorizing SSI and med refills. She feels badly about this and, with the next patient, she will choose her words more carefully. But perhaps this woman has been screwing over the system. NewFNP doesn't know and this patient just didn't seem to warrant the benefit of the doubt today.

Feeling uncomfortable with the secure prescription pad in hand is not a sensation newFNP likes to experience. Would newFNP have killed this woman if she write her for 20 or 30 lorazepam? Doubtful. Would the encounter have been more pleasant for the both of us? Certainly.

Monday, March 24, 2008

NewFNP returned from a quick yet lovely weekend trip to a nearby vacation island and was welcomed back to the clinic with a gloriously light day. Eighteen patients, two of whom were 'productivity boosters', a phrase newFNP has coined to describe patients for whom one signs a superbill yet who require minimal care, such as vaccine visits or family planning counseling visits.

The beauty of the light clinic day is that when a woman presents for her pap and casually mentions that she would like an IUD, newFNP offers to do it all at the same time. And voila! Five years of protection and a pap result on the way. Or when a patient happens to note that it has been three years since her last pap, newFNP does not feel a twinge of regret as she offers to do the pap right then and there and the patient accepts.

During a light clinical day, newFNP also has time to create an ongoing health maintenance flow sheet, something our charts lack and that has been bemoaned aplenty lately in staff meetings. Just give newFNP 10 minutes and she'll whip it up! Give her another 10 minutes and she'll research locums and on-call answering services! Hell, give newFNP an hour and she'll re-create every fucking form that sucks in the charts. Rocket science though these activities may not be, they are important in daily clinical life.

NewFNP also had an opportunity to continue her conversation with the doctor who so offended her the other day. Taking a chance, newFNP told her that she really had felt upset that it seemed that the doctor thought her voice was less important because she is an NP rather than an MD. NewFNP does believe this woman when she says that was not her intention. It calls to mind the importance how we use language and being mindful of other people. NewFNP is so incredibly guilty of intermittent foot-in-mouth disease. But it also made newFNP realize how important it is for her to a) feel like she is an important part of this team, motley though it may be and b) to feel empowered to speak out when she feels belittled or devalued.

If newFNP has a post-vernal equinox prayer, it is to continue with light clinic days. And to have J. Crew cashmere go on sale. And to have student loan debt bailout by JP Morgan Chase. Come on! Bail a hard-workin' sister out!

Wednesday, March 19, 2008

Now newFNP feels a little guilty, but feelings are feelings and newFNP felt offended. NewFNP may take this opportunity to do a little education about language and what may be construed as hurtful. However, the apology does engender some goodwill in newFNP's heart.

Oh, how the tide changes from one day to the next. Yesterday, newFNP was busy as hell, yet she didn't feel as though she had been crushed by a wooly mammoth when she returned home. In fact, as readers may recall, she actually felt wonderful.

Today, not so much.

Yes, it was busy. That is the only similarity. Busy, busy, busy with uncontrolled diabetics, physicals and a slough of other utterly non-interesting cases. And busy with an infuriatingly frustrating all-staff meeting-slash-clusterfuck at the end of the day.

It started out innocently enough. Introductions, welcome new staff, blah blah blah. Then newFNP's CEO moved on to the very touchy subject of providing decent care.

In newFNP's clinic, there is no such thing as patient flow. We do not have EMR; there are no reminder cards that it is time for your pap or mammogram or cholesterol screening. Patients come in waves - charts overwhelm the hard plastic bins in which they are placed while providers attempt to make it through visits. There is no urgent care clinic, nor are there hours set aside for urgent care. Walk-ins are folded into the schedule along with appointed patients. Sometimes appointments are cancelled when the front-desk floodgate is so widely opened that the walk-in deluge overwhelms capacity. Some providers see the expected amount of patients - about 25 per day. Others see far fewer.

These are a few of the issues in newFNP's clinic. Is it any wonder that we miss screening tests, the topic that opened this Pandora's Box? Theoretically, all it takes for a provider to miss something is too little time or too little motivation. At times, newFNP is sure that even the best provider has been overworked or lazy or distracted.

So what does newFNP's clinic want? Do they want thorough care or do they want fast care? Do they want urgent care or do they want primary care? Because they just cannot have both in the "system" currently in place.

And then to top it off, newFNP had her first real taste of subtle NP-bashing while chatting about these issues with three of the physicians and the CEO after the meeting.

"Really," the new doctor said, "I'm the only doctor in C. [her clinical site in a nearby neighborhood]." Directing her eyes toward the two other physicians, she continued, "I think we should get together and talk about these issues."

"Get together as doctors or get together as providers?" newFNP asked.

"As providers, if mid-levels are interested. I just don't see a lot of mid-level interest in these systems issues in C.," she responded.

Yeah, asshole, mid-levels are interested. NewFNP has been quite vocal about this for the past two and a half years. She has met with the CEO. She has talked to the CMO. She has discussed ideas with other providers. She brings up systems issues in every provider meeting. But unless management gets on board with these changes, newFNP may as well just spend her energy window shopping as Barneys because she is just as likely to have a closetful of Manolos and Marc Jacobs as she is to have these changes come to fruition.

What is more maddening is that, up until this comment, newFNP always felt like she had a respected voice in this discussion. It is fucking bad enough that the expectations for productivity are so high and that newFNP's patient flow is relentless. But then to be devalued by a provider who has been working part-time at the clinic for all of three months? NewFNP knows that there are physicians who just think that NPs and PAs are idiots, but aren't they smart enough to simply wait until the NP or PA leaves before they insult them? And if you think that NPs and PAs are lame, why in the fuck would you work in community health where there are tons of them!

Tuesday, March 18, 2008

It would have been easy for newFNP to just blow off the attitude of the almost thirteen-year old obese boy who begrudgingly attended his well child visit with his mom today. Eyes steadfastly examining a single spot in the floor, his 213-pound frame turned away from his mom and from newFNP, he initially refused to respond to newFNP's questions or to his mom's exasperated pleas for the responses.

"You see, Doctora?" she lamented. "This is how he always is."

NewFNP cares for this boy, his two younger brothers, his mom - who has diabetes - and his grandma who also has diabetes and who has had two strokes. His mom cares for herself, her mother and her four children as best she can. One older boy is on house arrest. As newFNP flipped back to the last physical, she saw in her handwriting: father incarcerated.

NewFNP knew that this attitude was about that. She asked the patient if his dad was still in jail - he is. She asked him if that was why he was upset. It was. She asked the patient's mom to leave them alone, not quite certain how to broach the subject of the kid's attitude and his father's incarceration. These topics are difficult for newFNP - she often feel like the emotional equivalent of a bull in a china shop when she has to discuss them.

True to that expectation, newFNP's start was rocky. She asked her patient, whose emotional pain was weighing heavily in the room, to please look at her. He refused. She told him that it would mean a lot to her if he could just look at her. He made a micro-movement toward her, decided against it and again faced the floor and told her no.

NewFNP said, and in writing this she knows that it is harsh, "OK, so you just want to sit here and be a jerk?" He said yes. This affirmation opened the door for newFNP to ask him who has told him that he is a jerk.

And the floodgates opened. NewFNP is not sure what she would have done if they had not but it doesn't take a psychic to know that this kid has had a lot of negativity directed towards him. 'Jerk' may have been tame compared to other names he has been called.

NewFNP spent the next twenty minutes listening to this devastated kid cry about how he misses his dad. It was absolutely heartbreaking. He doesn't want to go to school because his dad used to take him. He doesn't want to go to the park because he sees all the other kids with their dads. When someone picks on him at home, no one is there to defend him like his dad used to. He is about to turn thirteen and all he wants for his birthday is to visit his father in prison. He is concerned that he will be deported and that he won't see him again. His uncle is mean to him, tells him bad words and to "calm the fuck down." His aunt yells at him. His mom is frustrated with him.

NewFNP was, frankly, not sure what to do. Obviously, this kid is at high risk for school failure, perhaps for criminal behavior given that his brother and father both modeled it for him. NewFNP knows that he is also at high risk for diabetes, that he already has fatty liver infiltration and she assumes that part of this overeating has an emotional component. She made an executive decision to blow off the medical concerns for today - at least in part - and to focus more on his emotional decompensation.

She told him that he has already seen too much and suffered too much for his young life, acknowledged that life has dealt him an unfair hand, allowed him to grieve his loss and his loneliness. She talked to him about his potential, about making good decisions and about how he is loved. She told him that she saw a sweet person inside who wanted love and caretaking.

She just let him cry and tell his story as, in the world according to newFNP, telling one's story is an important therapeutic process.

At the end of the visit, newFNP listened to the kid's heart. She let him listen to it - it was the first time he smiled during the visit. She asked his permission to check his blood and ordered a cholesterol, a comprehensive metabolic panel and an A1c - just in case. She told him that she would see him in two weeks. The nutritionist referral will have to wait until then.

NewFNP left him in the room and spent a few minutes with his mom. She asked her to tell him every day that she loved him. She asked him to tell her bullying brother to lay the fuck off. She told his mom that she was very worried about this sensitive and hurting boy.

NewFNP was e-mailing a pal from public health school to ask about mentoring programs for this kid when she heard him call her name. She turned around and he gave her a big hug and thanked her.

Even though newFNP thought how she was utterly powerless to change this kid's life during her encounter with him today, she simultaneously felt so grateful for the opportunity to say kind words to a troubled adolescent. She needed that. Clinic has been so overwhelmingly thankless lately that she had been questioning whether or not she could stay.

Even though newFNP didn't do much medicine with this guy, she definitely did some nursing. And some social work. And it felt really, really good.

Saturday, March 15, 2008

Yesterday afternoon, as newFNP looked at the pregnant seventh grader sitting across the room from her, she searched her eyes for a glint of fear, of recognition of the gravity of her gravid situation, and for a seed of doubt that would allow newFNP to introduce the topics of abortion or adoption. She struck out. She brought them up anyway.

Perhaps it was because this young woman appeared to have the IQ of a toadstool. Perhaps it is because her sister is twenty-one and has five, yes five, children. Perhaps it is because her dad was deported a few years ago or because her brother recently died. Perhaps the ole 1-2-3-4 punch - shitty life circumstances leading to seeking love and affection in the arms and bed of a horny fifteen-year old boy, infinitely desirable in his scowl, his Nightmare Before Christmas hoodie and his Vans slip-ons.

Whatever the reasons, this just-turned-fourteen-year old girl was convinced that motherhood was the best option for her. OK. NewFNP took a deep breath, attempted to put her judgements aside and started talking more about self-care, about breastfeeding, about finishing middle school and then high school, about bringing her frigging mother to her next prenatal appointment.

NewFNP auscultated fetal heart tones, reviewed lab results, talked a little about fetal development and the importance of nutrition and then exited the exam room to have a shit fit and find the prenatal care coordinator who would hook this very young lady up with prenatal case management, parenting classes and God knows whatever else a fourteen-year old needs in order to become the best parent she can be.

NewFNP's prenatal care coordinator, PCC, is lovely. She is twenty-four and she also got pregnant for the first time when she was thirteen. As she tells it, her Pentecostal preacher father was none too pleased. She delivered her now ten-year old son at the age of fourteen and her daughter at the age of eighteen. Despite many bumps in the road with her children's father, they remain married and, as far as newFNP knows, happy. She started out several years ago as an MA in newFNP's clinic. Because she is personable and talented, as well as smart, she was promoted to the position of prenatal care coordinator and has done remarkably well with the new responsibilities.

NewFNP's patient is no PCC. NewFNP is concerned the PCC is the exception and newFNP's patient is the rule. Nevertheless, newFNP will continue to support her in having a healthy pregnancy and baby and, if she decides that adoption is a good plan after all, newFNP will be there with the referrals.

As an aside, since when are fourteen-year olds in seventh grade? NewFNP was a sophomore year in high school when she was fourteen. Aren't we at least supposed to be in ninth grade?

Thursday, March 13, 2008

NewFNP walked into clinic Tuesday - a different site from where she usually works - and her MA asked her to please take a gander at the little girl in room 3 with a rash.

A rash?? Holy shit, and how!

This little girl's skin was fucking polka-dotted. Ears, face, trunk, legs, arms, neck and -- hey there --palms and soles. Did newFNP mention that this four-year old's temp was 103? And that two of the lesions seemed purpuric. And that she showed increased work of breathing? And that she had conjuctivitis? And coryza?

Inside, newFNP was like this: Shit!! What the fuck? Help! Inside, newFNP asked the mom about medications. None. Known allergies? None. Travel history? None. Pain? None. Vaccines? No four-year old vaccines yet, but the girl was only two weeks past her fourth birthday. Otherwise, up to date. Onset? About twelve hours prior, as a single lesion on her arm. Scared? Yes. The patient and newFNP.

NewFNP must admit that her differentials included holy shit, what the fuck is this? and who fucking knows but she's going to the ED. NewFNP tried to calm herself down and think of what causes palmar rashes. Syphilis. Allergy. Help!

NewFNP ruled out syphilis because, high risk though her clinic may be, no -- just no. And her history didn't lend itself to the diagnosis of allergic reaction.

At this point, newFNP knew that she was dealing with a case requiring consultation. She called Dr. Dual-Ivy-League-Degrees who raised the concern for meningitis and supported newFNP's decision to send the girl to the ED.

The patient's mom offered to take the little girl on the bus. Gold star for flexibility, not so much for public health. NewFNP arranged alternative transportation and affixed a surgical mask to the girl's face in the off-chance that the rash was, in fact, meningeal.

NewFNP called the parents last night. The little girl was being discharged after having been observed for twenty-four hours for suspicion of the very freaky Stevens-Johnson syndrome. Apparently, she must not have had it or she wouldn't have been discharged, right? NewFNP is dying to read the hospital notes.

The ER docs attributed her reaction to a Motrin allergy. Now, newFNP did not get this information in clinic and actually gave the patient a whopping dose of Motrin to bring that fever down. Frankly, newFNP is suspicious of this diagnosis. Sure, she won't give Motrin to this patient in the future, but a temp of 103?!? Perhaps that is a confounder in this case.

Man, is newFNP ever lucky that this girl was her first patient of the day and not her last!

Sunday, March 09, 2008

If there is one thing to which newFNP is sensitive, it is to the discussion of acne.

NewFNP has frequently professed her love of Retin-A, but prior to extolling its virtues, newFNP was a begrudging fan of its stronger, more teratogenic cousin: Accutane. NewFNP's skin was not always so clear and lovely and newFNP felt quite unattractive as a result. By the time she got hooked on the Accutane, she had tried what seemed like trillions of topical and oral antibiotics, all to no avail. NewFNP was, by that time, very sensitive about her skin.

Therefore, when newFNP has a patient with acne, she broaches the subject gently. She may say something like, "NewFNP sees that you've been breaking out a little bit. Would you like her to write you a prescription to help with that?" This is perhaps the only circumstance in her life in which newFNP has never been refused. Patients generally want help and are thankful when the offer is extended.

NewFNP had a teenage patient in clinic for a non-derm related complaint last week. He sat on the exam table, his mom and 7-year old brother on the chairs. NewFNP addressed his complaint and then turned the topic to that of acne, which she acknowledged as being a normal and treatable adolescent process. Following the rule, newFNP's patient and his mom were grateful for the offer of help.

Thursday, March 06, 2008

School avoidance is a universal phenomenon. Say, for instance, you are a student at a very fancy, very name-brand nursing school and you are about to graduate and you have a horrible coma-inducing class from 5-7 PM on Thursdays. That situation is a perfect set-up for school avoidance!! Not that newFNP ever found herself in such a situation - she's just sayin!

Another universal phenomenon is that pre-adolescents and adolescents are embarrassed by their parents. One day, Madonna's kids will be embarrassed by her. Brangelina's kids will lament their misfortune at having such uncool parents. George Clooney may possibly escape this phenomenon, but as far as newFNP knows, he is sans progeny, so we will never know.

Well, one thing that might make a kid want to avoid school is if kids in your 7th grade class made fun of your mom. And one thing that might make kids make fun of your mom is if she showed up to pick you up, was overweight, yet wearing a leopard print halter top showcasing striated bosoms, white denim Daisy Dukes and had an unfortunate home experiment with bleach technology - 4 to 6 weeks ago if newFNP correctly noted the root growth - thus rendering her hair a Tony the Tiger shade of orange.

NewFNP remembers feeling horrified that her mom had the lamest jeans. And they were full length and she probably had a regular sweater or lady-blouse and some sweet baby-blue high-top Reeboks circa 1985 and had respectable highlights. NewFNP's mom was known as a cool mom and newFNP still felt embarrassed by her.

This poor little guy must have felt really bummed - newFNP can only imagine what those sharp-tongued little 13-year olds said to her patient.

But what it is about a parent that makes her not intuitively get that dressing like a Kit Kat Club dancer is no way to roll when you're picking the kids up from school? Or ever! Just throw on some sweat pants and a smart cardigan before you roll up on the middle school, for Pete's sake.

Monday, March 03, 2008

NewFNP has recently begun to wonder more and more -- is she part of the solution or part of the problem?

NewFNP is type A to the nth degree, she is a stubborn Capricorn and she is addicted to having things done correctly, generally on the first try. She is unfailingly punctual. She expects that the people with whom she works will get their jobs done correctly so that her job is easier.

Perhaps these personality traits are more suited to, oh let's say, dictator than to that of an FNP in a community health clinic. While newFNP knows that her expectations oftentimes exceed the ability of her support staff and sometimes of other clinical staff, during a busy clinical day in which newFNP is correcting the mistakes or oversights or laziness of others, she cannot help but to grow frustrated.

NewFNP is so used to having things screwed up that she perpetually dreads and anticipates the mistake du jour.

For instance, last Friday, three providers were scheduled, two were working and zero patients were cancelled until newFNP had a fit of apoplecty in front of the clinic manager and scheduler.* Today, one of newFNP's clinical colleagues left early and newFNP was overly sensitive to ensuring that the front desk staff was aware of her departure and would allow for a reduction in patients as a result of having one less provider. NewFNP is so sensitive to foolishly booked schedules that she was unable to see her way through the management of two physicals scheduled at the same time - mom and baby - who arrived an hour late and wanted to be seen together. Though not an unreasonable request, it seems more unreasonable when A) the one month old boy's father was present and B) the pair were an hour late.

NewFNP is confused. She has autonomy in her practice, the physicians do not see her as incompetent or "less than" because she chose to be a nurse rather than a doctor, she has decent benefits and a reasonable salary, although that last point is negotiable.

But is newFNP doing any good when she feels like she is walking into the DMZ as she crosses her clinic's threshold? Do other providers have to remind themselves to smile? Is her frustration causing her circulating cortisol level to rise to the point where newFNP will be rendered infertile and laden with belly fat? Will she need therapy, IVF and relacore?

Is it worth it? Is this just what it is, what it always will be?

In writing this, newFNP thinks back to this morning when she arrived at her desk to find a sweet coffee cup, wrapped in paper towel - a gift from a patient. So lovely and sweet. Is newFNP an asshole for thinking of leaving these sweet patients, frustrating though they and the practice may be?

NewFNP is holding out for the four-day workweek. Rumors have been circulating that the clinics may open for extended hours. Three days off each week might be the ticket. Hiking, movies, yoga, hair-dos, shopping, cooking. That may just turn over a new, happy leaf in newFNP.

Saturday, March 01, 2008

There are aspects of any new NP's experience that are less than savory. These may include the retrieval of a malodorous weeks-old feminine hygiene product from a vagina, the careful examination of moist fungal foot lesions or the olfactory assault during the always enjoyable abscess incision and drainage.

NewFNP wouldn't say that she would opt to participate in any of the aforementioned activities, but she is aware that certain complaints require certain assessments. For instance, if you tell newFNP that your ear hurts, you can bet that she will check out the affected ear(s) as well as the associated lymph nodes and she'll throw in a oropharyngeal exam at no extra charge. If your va-jay-jay has taken a turn for the worse, newFNP will have you in the lithotomy position as fast as you can say "wet mount."

And if you tell newFNP that your prostate is acting up, that you're having decreased urinary stream and that it hurts to ejaculate, newFNP will think, "Crap - prostate exam" -- no pun intended.

When newFNP informed her patient that he was soon to be intimately acquainted with her gloved finger, he told newFNP that he would rather not. NewFNP, somewhat relieved, stated that she would draw the PSA and, if abnormal, would conduct the DRE. He seemed dissatisfied and told newFNP that, if she wanted, he would consent to the DRE.

If she wanted??

Honey, when it comes to prostate exams, want does not come into it. Begrudging acknowledgement of necessity, yes. Desire, no.

This blog is for new NPs or NP students who want some real 411 on the life of a new practitioner. A new practitioner in a busy, understaffed, urban community health clinic in a major metropolitan area. Oh, and newFNP swears while writing and, sometimes, while working although she tries to keep those swears to herself. Consider yourself warned.